The four domains of nursing leadership

Patient safety: the four domains of nursing leadership

Pamela A. Thompson

GO INTO ANY AIRPORT BOOKSTORE and you’ll find there’s no dearth of ink that’s been spilled on the topic of leadership. Catch up on your professional journals and you’ll find the same thing regarding patient safety. But how can we isolate the unique challenges nurses face as leaders trying to advance a patient safety agenda in their practice environments? To tackle this question, it is helpful to consider the patient safety agenda reflected in four domains: leadership competencies, culture, shared leadership, and external partnerships. Together, these domains present a clear picture of the areas nurse leaders must focus on to be successful.

Nurse leaders who are strong in each of these areas can go beyond merely influencing their organization’s patient safety strategy to actually designing it. Because of the nurse’s central role in the hospital, she/he is in an ideal position to create and drive the patient safety strategy. After creating the strategy, it is up to the nurse leader to work with other groups to make it a part of everything the organization does. Visualize the organization and its activities as a piece of white linen cloth, with patient safety as a red satin thread woven through it. You can see the red thread very clearly both as a separate thread and as an integral part of the fabric. If you pull the red thread out, the integrity of the cloth is lost.

Leadership Competencies

Leading an organization-wide patient safety effort requires nurse executives to couple exceptional leadership skills with a keen focus on patient safety. They must approach the challenge from a systems perspective while leveraging the voice of the bedside nurse–the voice of a strong patient advocate and of someone who understands how to work as part of a care team.

Fortunately, our profession has several strong resources for leadership competency. In February 2005 the American Organization of Nurse Executives (AONE, 2005) released its Nurse Executive Competencies; a related assessment tool for nurse managers is forthcoming. In brief, AONE believes nurse leaders at all levels should be competent in communication and relationship-building, knowledge of the health care environment, leadership, professionalism, and business skills. The AONE 2005 strategic plan includes patient safety as a major initiative. Part of that initiative includes defining the nurse leader core competencies for patient safety.

The American Nurses Credentialing Center’s (ANCC, 1993) Magnet Recognition Program contains the “Fourteen Forces of Magnetism,” developed in 1993 from work begun a decade earlier by the American Academy of Nurses in its attempt to identify the qualifies of hospitals that are able to attract and retain professional nurses in the face of a critical shortage.

The National Patient Safety Foundation (NPSF) also offers several resources to help nurse leaders lead patient safety efforts while collaborating with patients and their families. One of the best is Patients and Families in Patient Safety: Nothing About Me, Without Me (NPSF, 2003), a call to action for health care organizations to involve patients and families in systems and patient safety challenges. Areas of focus include education and raising awareness about patient safety, culture, research, and support services to mitigate the effects a harmful error can have on families. Finally, several reports from the Institute of Medicine (IOM) Health Care Quality Initiative (1999; 2001; 2004) are invaluable resources for nurse leaders at various stages in their initiatives.


The culture of safety described by the IOM emphasizes the need for leaders and managers committed to promoting safety at all levels of the organization. It empowers employees to watch for potential problems that need to be addressed. It encourages open communication among staff and management. It requires that staff be properly trained and educated regarding patient safety and prevention. Finally, it requires adequate resources and infrastructure so staff can function efficiently and effectively (IOM, 2004).

Driving cultural change is perhaps the most critical role of the nurse leader, who must rally staff, departmental managers, and administrators onto the patient safety bandwagon. While cultural change must target everyone in the organization, particular emphasis must be placed on nurses. They are the largest group of health care providers in the hospital, are generally closer to patients than other clinicians, and spend the most time in the patient care departments. Hence, they are the most likely to recognize workflow, physical plant, or communication-related issues that give rise to patient safety problems and also to identify possible solutions and work to implement them. In one well-known study, nurses were responsible for intercepting 86% of medication errors before administration, a rate far higher than at any other stage of the medication use process (Leape et al., 1995).

Much has already been written around cultural change, notably how difficult it can be to move from a mostly silent, hierarchical culture of blame to an open, team-oriented culture of safety. A good place to start is by administering a safety culture assessment throughout your organization. One that is particularly useful is the Agency for Healthcare Research and Quality (2005) Hospital Survey on Patient Safety Culture. The results will not only provide a baseline from which to work but it will help raise safety awareness throughout the organization and identify areas most in need of improvement.

Shared Leadership

If the hierarchical leadership model can hinder patient safety goals, shared leadership, its antithesis, can advance them. The goal of shared leadership is to create an environment of interdependence that values the expertise of staff at all levels. Similar to effecting cultural change, transitioning to a shared leadership model begins by assessing where staff falls on the spectrum between hierarchical and shared decision-making models, then following up with education and training.

For shared leadership to take hold, the nurse executive must push its tenets through the entire organization, including into the “C-suite” and up to the boardroom. Nurse leaders must adopt a fiscal mindset about patient safety without losing the clinical perspective. Translating patient safety needs into business terms and constructing a business case with powerful return on investment measurements is essential.

External Partnerships

Nurse executives can forge strong partnerships outside of the organization that can help further the patient safety agenda. This includes partnerships with colleagues in academia; information technology and other industry vendors; patients and families; the board of trustees; state, local, and possibly federal government; and professional associations. Partnerships with physicians are critical because most physicians are not employed by the hospital and may view their participation in patient safety efforts as optional.

In the academic setting, nurse leaders must work with educators to assure that students receive real-world practice around patient safety issues. It is essential that we find better ways to assimilate students into the work environment so they don’t arrive ill prepared to practice as part of an interdisciplinary team.

In this arena, again, several excellent resources exist. In 2003, AONE released a toolkit on CD that provides resources for assessing partnerships with local nursing schools and identifying opportunities for improvement (AONE, 2003). It focuses on how to begin the kind of dialogue described earlier and how to work together to develop programs that better serve the community’s needs. In addition, other materials are needed in the areas of preceptor agreements, mentorship models, and model curricula.


The role of the nurse leader in patient safety can be characterized as follows: to establish the right culture; to infuse that culture with shared leadership so that the expert voice at the bedside is really defining the work; to possess the competencies necessary to coordinate and advance this complex initiative; and to forge both internal and external partnerships, because we will not be able to do this work alone. To further the work on this topic, nurse leaders who participated in the Nursing Leadership Congress are committed to identifying additional resources to help nurse leader colleagues drive patient safety efforts throughout their organizations.


Agency for Healthcare Research and Quality. (2005). Hospital survey on patient safety culture. Retrieved from qual/hospculture/

American Nurses Credentialing Center (ANCC). (1993). Fourteen forces of magnetism. Retrieved from

American Organization of Nurse Executives (AONE). (2005). AONE nurse executive competencies. Retrieved from http://www.–final% 20draft–for%20web.pdf

American Organization of Nurse Executives (AONE). (2003). The nursing practice/education partnership assessment guide. Chicago: Author.

Institute of Medicine (IOM). (2004). Keeping patients safe: Transforming the work environments of nurses. Washington, DC: The National Academies Press.

Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: The National Academies Press

Institute of Medicine (IOM). (1999). To err is human: Building a safer health system. Washington, DC: The National Academies Press

Leape, L.L., Bates, D.W., Cullen, D.J., Cooper, J., Demonaco, H.J., Gallivan, T., et al. (1995). Systems analysis of adverse drug events. Journal of the American Medical Association, 274(1), 35-43.

National Patient Safety Foundation (NPSF). (2003). National agenda for action: Patients and families in patient safety. Nothing about me, without me. Retrieved from pdf

PAMELA A. THOMPSON, MS, RN, FAAN, is Chief Executive Officer, American Organization of Nurse Executives, Chicago, IL.

MARY BETH NAVARRA, MBA, RN, is Vice President of Medication Safety, McKesson, Pittsburgh, PA.

NICOLE ANTONSON, MBA, RN, is a Program Manager, McKesson, Pittsburgh, PA.

NOTE: This article is based on proceedings from the first annual McKesson/Intel Nursing Leadership Congress, held June 2-3, 2005, in Sonoma, CA. More than 75 senior nursing executives from around the country convened to collaborate on best practice approaches to medication safety and to begin developing practical tools tied to recommendations that can be used in our nation’s hospitals. The invitation-only event was co-sponsored by McKesson and Intel, in collaboration with Joint Commission Resources, the National Patient Safety Foundation, the American Organization of Nurse Executives, and the Institute for Safe Medication Practices.

ABOUT THE NATIONAL PATIENT SAFETY FOUNDATION: The National Patient Safety Foundation (NPSF) was founded in 1996 by the American Medical Association, CNA HealthPro, 3M, and contributions from the Schering-Plough Corporation. The NPSF is an independent, nonprofit research and education organization. It is an unprecedented partnership of health care practitioners, institutional providers, health product providers, health product manufacturers, researchers, legal advisors, patient/consumer advocates, regulators, and policy makers committed to making health care safer for patients. Through leadership, research support, and education, the NPSF is committed to making patient safety a national priority. For more information, visit

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